Medical Records Release Request Form

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MEDICAL RECORDS RELEASE REQUEST FORM
I HEREBY AUTHORIZE AND REQUEST YOU TO RELEASE MY
MEDICAL RECORDS TO: DR. SHEERA SIEGEL
ADDRESS:
10 JAMES STREET, SUITE 140
FLORHAM PARK, NJ 07932
TELEPHONE: 973 665 8100
FAX: 973 665 8097
SPECIAL INSTRUCTIONS: PLEASE SEND FIRST AND LAST
MEDICAL NOTES; LAST 3 LAB RESULTS; ANY WRITTEN
COMMUNICATIONS BETWEEN DOCTORS; ANY RADIOLOGY
STUDIES; AND ANY PATHOLOGY REPORTS.
PATIENT NAME ________________________ /_______________________
First
Last
DATE OF BIRTH _______/_________/________
mm
dd
yyyy
ADDRESS ____________________________________________
_____________________________________________
_____________________________________________
SIGNATURE ____________________________________
RELATIONSHIP TO PATIENT __________________
DATE _____/______/________
____ CHECK HERE IF I WILL BE PICKING UP MY MEDICAL
RECORDS IN PERSON.

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